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City of Cerritos

Low-Income Water and Sewer Utility Assistance Program Application

Customer Information

Customer Name:

Service Address:

Account Number:

City, Zip Code:

Phone Number:

Email:

CARE or Public Assistance Program Participation (Required)

Applicants must either be currently enrolled in the California Alternate Rates for Energy (CARE) Program or in one of the eligible public assistance programs below. Enrollment must be active at the time of application and during each recertification period.

Please check the program you are enrolled in:

Energy and Utility Assistance Programs:

California Alternate Rates for Energy (CARE), including SCE CARE / SocalGas CARE

Family Electric Rate Assistance Program (FERA), including SCE FERA

Energy Savings Assistance (ESA) Program

Low Income Energy Assistance Program (LIHEAP)

Income and Cash Assistance Programs:

Supplemental Security Income (SSI)

Temporary Assistance for Needy Families (TANF)

Health and Medical Assistance Programs:

Medi-Cal

Housing and Family Support Programs:

Emergency Rental Assistance Program

Head Start

Food and Nutrition Assistance Programs:

CalFresh

Women, Infants, and Children (WIC)

National School Lunch Program

Tribal and Federal Social Service Programs:

Social Service Programs through Indian Affairs

Required Documents (Check all that are included):

Proof of enrollment in CARE or an approved public assistance program checked above

Completed application (recertification required every 24 months)

Copy of a valid driver's license or government-issued ID

File Upload:

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Initial Here:

Important: Name and address on the water account must match the approved program account.

Certification

By signing below, I certify that I reside at the service address above and am enrolled in CARE or an approved public assistance program.

Name on Bill:

Date:

Signature:

Clear